A Rural Emergency Direction for Alberta:

An Alberta
Rural EMS Direction
RED doc 3
Prepared by Dr. NJ Marlett (University of Calgary, Faculty of Medicine) & HR MacLean (Consultant)
for RED Committee of the Provincial Partnership to Support Community First Response
MAY 2012
RED doc is a discussion tool for communities and stakeholders wishing to understand the need for a
flexible, coordinated and accountable Rural Emergency Response.
The partnership is a growing network of Rural Mayors and Emergency Service providers, with
representation of AUMA, AAMDC, Fire Chiefs of Alberta and includes the input of Health Care
resources, researchers and concerned citizens.
Contact Mayor Barb Sjoquist for information or to connect to a partner near you: 780.755.3933 [email protected]
Updates: March – April 2012
 Meeting with Minister Fred Horne to present the RED doc.
This was a very positive meeting and the minister came to
understand the complexity of a rural 911 and emergency
response. He offered his support in opening a review.
 Health Quality Council review of EMS announced with
reference to RED doc concerns
 Minister using RED doc in meetings with AUMA, AAMDC
and communities
 Agreement with Fire Chiefs of Alberta to work together to
promote rural first response. Representatives chosen
Updates: May 2012
 New municipalities continue to join the partnership
 Preliminary meeting with Health Quality Council staff
 Partnership meetings to plan future meetings and
review documents
 Paramedics and Ambulance providers have been
studying RED doc and asked that their roles be
 Study of culture of urban fire and ambulance to better
understand rural history and culture
 Meeting with STARS senior management
The Trigger
Why we are concerned about the provincial approach to EMS
Threat to integrated 911 call and dispatch centers
Fragmentation of coordinated emergency response and teamwork
between Ambulance, Fire, Community First Response
Marginalization of the traditional role of Fire Departments in
Community First Response
Confusion in authority, responsibility and accountability among levels
of municipal and provincial governments and departments
The Rural Response
Partnership to support Rural Community First Response
Who we are and what we’ve done…
March 2010 - Health Minister declares ‘Hold’ on Ambulance Dispatch
July 2010 - EC911 Risk Management study for the Health Minister
 Nov. 2010 , Wainwright Meeting formed Partnership to Support Rural First
 Aug. 2011, Stettler - Provincial Partnership conference provides data on
shared issues
 Fall, 2011 – AUMA & AAMDC pass resolutions on halting transition &
negotiating 911 cell phone fees
 Nov. 2011 - Research report from Stettler conference distributed
 Feb. 2012 – RED doc released as living, action document
 April 2012 - AUMA Research being compiled & Heath Quality Council
review requested on EMS transition
Our Call to Action
Communicate, research, learn about, work together, and become politically active to
recognize, protect and advance a Rural EMS Direction (RED) that includes
3 Key Principles:
1. Ensure community
capacity for First Response
in medical emergencies
2. Ensure coordinated
provincial 911 network that
includes rural call and
dispatch centers
3. Accountability of costs
and quality outcomes
Why is a Rural EMS Strategy needed?
Remote and Rural areas require flexible strategies that reflect their
unique and changing strengths and needs.
Borderless ambulance dispatch uses rural ambulances to support urban
response time targets, increasing rural risk.
 Many remote and Rural areas do not have adequate telecommunication
 Rural Health profile is distinct (more catastrophic accidents, older
population, fewer health resources, lower income.)
 Trauma profiles are more severe –farm, hunting, resource industry
accidents, road accidents marked by faster speed, more rollovers.
 Rural EMS could provide a broad range of health supports in rural
Alberta if communities are involved in the development.
 Ambulance ground response is costly and prone to being outside the
windows for effective response time.
 Definitions for ‘Rural’ and ‘Remote’ rely on population size and
density, and the distance to services.
 In Alberta, there is a belief that most of the population lives in
Edmonton and Calgary with a scattering of medium sized cities.
 Popular belief that 95% of the province claims to be rural and
 AHS has a ‘Rural’ research division that is working on a
comprehensive mapping system of rural factors that could be
used to create logical rural EMS divisions within either a
provincial or zone model.
What’s at Stake?
 Local preparedness to respond to accidents and health crises in Rural Alberta
... The length of time for each emergency event is very short but these events
change peoples’ lives and community identities.
Some of the types of incidents that are involved: four teens roll over while rounding a
curve at high speed coming home from ‘after grad’, a senior slips while canning and
breaks her hip, a child chokes on a small candy, a man cuts his leg when clearing land,
a small plane crashes into a lake in a remote area. All need immediate attention.
 What generally happens: locate the person in need, dispatch emergency
personnel including a fast response to stabilize the situation and the health
condition, provide medical assistance on scene, transport to nearest or most
appropriate health resource, provide support and follow up to family and
community, and learn from experience and data collected.
Principle 1
Ensure Community Capacity for First Response
in Medical Emergencies
• Community First Response (CFR) is key to sustainable rural
municipalities. Capacity depends on local engagement and
collaboration with EMS and Police.
• Municipalities are competent and willing to work for change
but feel disenfranchised. The centralized plan has disregarded
municipal expertise and created major risks.
• Fire based First Response was and is developed and resourced
by Rural municipalities.
Community Health Capacity
Technology cannot replace Social Capital
 Everyone needs the security of knowing that there is
support close by to assist in an emergency.
 Local knowledge of locations, family health history and
networks, and informal resources are the social capital of
health when institutionalized health care is far away.
 Rural communities exist through informal networks. This
is lost in systems that are ‘centrally based and controlled.’
 International EMS research supports policy that enables
rural and remote areas to create flexible EMS, responsive
to local needs and resources.
See the Community Health Capacity Study guide
The search for an Alberta Solution:
The One Health Solution
A Coordinated Alternative
 All areas should receive
 Build on local strengths
same level of service
 Assumption of cost
savings in economies of
scale and unification of
practices, equipment and
and needs to increase local
capacity to respond
 Rational Network of
Dispatch Centres acting as
one but responding to and
accountable for local
The search an Alberta Solution:
The One Health Solution
A Coordinated Alternative
• Getting help fast: Technology will
• Coordinated 911 dispatch of best
locate and enable seamless
ambulance dispatch to get ALS to the
health event
• Quality of Care: Control of all ALS
trained staff. Reduce ALS trained staff
and emergency equipment from Fire
First Response.
• Transportation: No boundaries, all
• Team response with CFR with BLS
training augments other health
• Ambulance specific to region,
ambulances the same. Paramedics
practice where needed, ambulances
purchased to meet local needs
(smaller for urban settings, large for
long hauls, 4x4 for remote areas).
Expand options.
• Monitoring and accountability:
• Accountable to municipalities,
EMS accountable only to AHS.
local resource available including
fire first response, police and
AHS, Public Safety. Data open
Recognize Rural Health Capacity
 Actively encourage community groups, schools, councils to work on the
Community capacity study guide and share their results.
 Cooperate with Health Quality Review to investigate financial and social
costs of Transition. Investigate roles and responsibilities for all partners.
 Based on international research, negotiate EMR training and protocols
 Promote incentives for rural options that increase collaboration between
 Increase ALS within Rural Fire First Response rather than reduce it.
Principle 2
Ensure coordinated Provincial 911 Network that
includes Rural Call and Dispatch Centres
• 911 is the first call for emergencies. 911 generally is a public service that
connects or dispatches Fire (Municipal Affairs), Police (Solicitor General)
and Ambulance (Health) services.
• It can be provincial, regional or municipal with call transfers to service
providers or to local dispatch.
• A Rural 911 call and dispatch strategy would act as part of a provincial/zone
• Rural 911 would combine seamless call and integrated dispatch of fire and
• The risks of relying on 911 cell phone location information needs to be
addressed separately.
Roles in Rural Integrated Dispatch
Ground and Air
assess needs, on scene
medical attention,
transport and pre
hospital care
Community First
Response (Fire):
stabilize medical situation
prior to ALS/BLS
secure dangerous
situations, conduct
Fire/ Emergency service:
Rural 911
secures scene, land air
ambulance, extricate and
load patients, provide
community follow up
Community Resources, Local Businesses, Local Health Care providers, Citizens
Rural Alberta Dispatch
 Rural areas pioneered coordinated dispatch and by
the early 1990s rural 911 dispatch was funded by
municipalities working together.
When events cross boundaries, mutual agreements
are in place to coordinate large scale responses.
Rural dispatch hires local people with intimate
knowledge of resources, locations and routing.
Rural Coordinated Dispatch provides ‘command
centre’ functions for local emergency events.
Smaller rural centres are quick to adapt to change.
Personalization of service protocols
Rural Alberta Fire Fighters
History of Community First Responders
 All Fire Fighters were trained in Basic Life Support. As the need for Advanced
Life Support increased Fire Fighters advanced their training to reach an ALS
standard. In some centres, entire Fire Departments were ALS trained. Medical
oversight was provided by local physicians.
 ALS trained staff were in demand and many left volunteer positions for full time
employment in Cities. Rural Fire was faced with training new recruits to cover
ALS needs and this became a serious drain on resources.
 In Urban centres, Paramedic services aligned with Ambulance. This was not an
issue in Rural areas because there were so few ALS trained staff. Innovative
cross trained or coordinated situations were created.
 With consolidated AHS dispatch, First Responders are less frequently dispatched
and Fire Fighters with ALS training have been actively discouraged from practice.
 A growing number of Rural Fire Departments and Municipalities have chosen to
continue to provide ALS service as part of their First Response and their normal
Emergency and Rescue operations.
Rural Alberta Fire Departments
Current Situation of First Responders
 Fire/Emergency Services departments provide emergency
preparedness, response and follow up. Medical first response is
a natural part of the existing mandate.
 Administrative home for First Response: staff call out,
emergency vehicles, equipment, organization, record keeping ,
training and recruitment, accountability.
 Dispatch protocols are negotiated with local Fire departments,
municipalities, EMS/AHS – flexible and diverse contracts make
maximum use of resources.
Please refer to notes: Approved Scope of Practice for Fire based First Responders
Rural Alberta Fire Departments
Issues related to First Responders
 Fire Departments have many specialties that require extensive training and
support. Because AHS does not understand or support First Response there is
a struggle in some municipalities to continue to pay for the First Responder
advanced skills training.
 Training has been informal or contracted through Red Cross, St. Johns
Ambulance using their national accreditation. These are affordable and do not
require expensive certification.
 Rural Fire Departments are volunteer and are concerned about the expected
costs of standardized training and certification though the College of
 Research seems conflicted about the need for ALS trained First Response and
municipal governments question the economics of advanced training when
graduates are lured into cities.
Please refer to notes: The need for a specific Rural First Response Protocol
History of Alberta Paramedics
in Alberta
 1971 - SAIT/NAIT Advanced Life Support Paramedic
1985 - STARS first flight, paramedics central to service
March 2005 - Iris Evans, then Minister of Health,
cancels AHS plans to transition EMS due to cost
April 1 2009 - AHS transitions EMS to province
April 1 2010 - Cochrane/Airdrie/FREMS transition to
April 1 2012 - Canmore last town to transition to
direct delivery of EMS to AHS
Issues of Alberta Paramedics
 With transition, pay grades were increased dramatically but
the problems with reduced benefits and infrastructure
problems with dispatch have created discontent.
 Currently paramedics are employed by Fire Departments and
Ambulance services. Conflicting directions are emerging.
 EMS practitioners feel that AHS is moving the profession to a
more “technical and less clinical role” to reflect future pay
 The College of Paramedics began working to become
recognized within the Health Professions Act in 2006 but have
not yet been accepted.
Anatomy of a 911 call in Rural
Alberta in non-transitioned areas
Call received at regional site
1. Secure and verify location
2. Dispatch from regional site
• Dispatch First Response
• Dispatch Ambulance
• Dispatch Fire Department
• Transfer call to Police/ RCMP
• Dispatch other community resources
3. Coordinate response though communication
Infrastructure, call monitoring. Support linkages and
4. Collect, Manage Data on Response and Outcomes
Anatomy of a Transitioned 911 Call
 In post transitioned dispatch regions there are serious
risks that are being mitigated by the 911 centres.
 The complexity of the routing and back up systems
create many more steps than in an integrated dispatch
system and thus more chances for delays and
 The added work involved in this new system is costly
and the costs are being born by the dispatch
centre/member municipalities.
Essential Elements of Rural 911
 Linked PSAP (Public Safety Answering Point) can create a
unified provincial 911 service
Trained dispatcher to answer call, dispatch service and
coordinate response. In UK, dispatch is part of treatment.
Negotiated dispatch protocols with municipalities, Fire
departments, designated First Responders, local resources.
Need to tailor protocols to ensure maximum participation.
Unified tracking of call, response and outcome measures
throughout the provincial or zone system
Accountability systems for costs for all services
Cell phone / 911: DISCONNECT!
 Cell phone use in Rural areas is rapidly increasing.
 Encourage citizens to pay attention to where you are, because cell phones
are not as reliable as land lines in locating calls.
 Six provinces have legislation related to 911 and collection of 911 monthly
fees to pay for 911 centres: Quebec (40 cents), Saskatchewan (62 cents),
Nova Scotia (43 cents), New Brunswick (53 cents), PEI (50 cents) and
Manitoba (in process).
 Regulations governing Cell phone accuracy rest with the CRTC.
 VOIP: disconnect between service or billing address and the actual
 Minister Service Alberta/ Municipal Affairs to take the lead on 911
legislation and administration; cannot be done by one of the emergency
Please refer to notes on Cell phone issues from the Stettler conference
Rural 911 Strategy
 Research, Negotiate and Introduce 911 legislation
with Provision for Rural Strategy: mandate,
resourcing, standards cf. provincial summaries of
 Negotiate and research a Provincial 911 Network
that includes Rural 911 call and dispatch centers.
 Ensure protocols for ‘default’ First Response
dispatch in Rural Settings.
 Research and negotiate shared equipment,
reporting, accountability and review process.
Principle 3
Accountability of Costs, Services and Outcomes
For spending and contracting
For quality of care – tracking calls and outcomes
For a shared and transparent set of criteria for
positive and negative outcomes
For complaints and concerns
Access to Health Quality Council for disputes
Please see notes for description of above issues
Uncovering the Hidden Financial
Costs of Transition
 Before transition, reciprocal agreement were in place
between the various services to balance costs.
AHS is assuming authority over EMS Medical Services
without negotiating or financing the services that they
now expect.
Municipalities are expected to assume rising costs that
result from recent service fragmentation.
AHS expects communities to provide Community First
Responders who will work for AHS.
Who is keeping track of the direct and indirect costs of
Uncovering the Hidden Social
Costs of Transition
 Before transition, most medical emergencies were handled
by a consistent local team of Fire First Response, local
ambulance and RCMP. This is breaking down.
 In many towns a divide has been created as municipalities
consider removing ALS fire first response to qualify for AHS
payment of Ambulance/ALS
 There is a strong impression among seniors that the
degradation of fire first response compromises the rural
safety net. Many now feel that they are only safe in a large
urban setting.
 Loss of Identity for Community First Responders
 Investigate Social and Financial costs of
Transition (Health Quality Council)
 Introduce common system for tracking health
related costs in First Response
 Shared and transparent outcome criteria
among Dispatch and Emergency Medical
Response, e.g. UK criteria
We respectfully submit that it is
possible to achieve a RED Strategy
It would meet the expectations for a system that is provincial in
principles, standards and function, that:
 coordinates technology, dispatch and response protocols,
 ensures upgrade and support for the training of First Response
personnel at the community level,
 is capable of common data systems and accountability,
 rebuilds the Rural emergency medical team that has been the pride of
It would be based on three principles of Rural Health sustainability:
 Emergency Health capacity of individuals, families and communities,
 Collaboration at call, dispatch and service,
 Accountability and monitoring.
Appendix Review of Research & Policy:
First Response and Coordinated 911
Review of international literature using filters: Rural Emergency Medical
Response and First Responders.
 EMS is a new and evolving field of practice that bridges health and
public safety and is affected by the legislation of many different
 EMS is becoming more integrated into the Health Care continuum but
supports local initiatives and partners.
 EMS is a site of incubation of ideas, reform and communitization of
 Provincial models are living labs of centralized and coordinated
Please view notes: an international set of research and policy websites

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